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Pathologizing the norm

At the beginning of any introductory psychology course, students are warned that the basic education they are about to receive does not make them experts in the field. They are cautioned against diagnosing friends and family members with their scant knowledge, and they are reminded that there are innumerable nuances in both personality and personality disorders that they are far from privy to. A stirring op-ed piece in the New York Times recently highlighted some of the perils stemming from the common citizen diagnosing themselves and their loved ones with Alzheimer’s disease or dementia. However, more and more it seems that clinicians and researchers in the field of psychology and psychiatry are at risk of making this same mistakes by pathologizing natural neuropsychological slips and common cognitive errors.

Neuropsychological assessments involve a series of challenging–and at times painstaking–tests of memory, decision-making, and cognitive flexibility, among other executive functions. Standardized ranges are provided for these scores from the wider population, similar to an IQ test. These assessments are particularly useful in neurological patient populations, such as victims of a stroke or a brain tumor, and in the elderly to assess cognitive decline, just as the DSM-IV (Diagnostic and Statistical Manual of Mental Disorders) and MMPI (Minnesota Multiphasic Personality Inventory) are helpful in a therapist or clinician’s office. However, these tests, as well as “significant” real-life examples, are now being used as evidence of disorder in normal individuals.

Nowadays, misplacing your car keys can be seen as a precursor to dementia and blanking on an old acquaintance’s name is indicative of Alzheimer’s. Likewise, niche expertise is an example of savantism and social awkwardness a sign of long undiagnosed Asperger’s syndrome, which is just a short step away from autism on the spectrum.

But what we have to remember–and what is getting lost in this dichotomous system of diagnoses–is that all of these disorders or impairments lie on a spectrum. And the ultimate litmus test for a disorder is not how poor one’s verbal recall is, but how much distress this impairment causes. The world of psychiatric and neuropsychological diagnoses is far from clear-cut, and these classifications must be based on more than just behavior. The perception and attitude of the patient must be taken into account, including whether the individual even considers themselves to be a patient in the first place.

Similarly, over the past twenty years, the diagnosis of ADD/ADHD (attention deficit / attention deficit hyperactivity disorder) has risen dramatically, as has the subsequent backlash against over-diagnosing and over-medicating society’s children. Before running to the doctor’s office or the prescription pad, it is important to remember that kids are squirmy, and no one, college students and professors alike, can maintain disciplined attention during a tedious lecture.

Everyone experiences memory loss as they age, just as we all feel sadness over the course of our natural cycle of emotions. Unhappiness is a universal human feeling that everyone must go through from time to time, and it is not indicative of the pervasive demoralizing morose of true depression. Emotion, attention, and memory are all fluctuating human traits and must be remembered as just that: natural and transient. Our culture is so eager for a quick fix, to get rid of any feelings of discomfort and receive instant release. But sometimes it is important to experience these sentiments, to sit and work through our problems and wrestle with our shortcomings. This is in no way meant to minimize the tribulations that accompany these very real disorders, but to serve as a reminder that all of us are flawed, mentally, physically, and emotionally, and if we pathologize these feelings, these struggles, then we may miss out on the robustness of life.

9 thoughts on “Pathologizing the norm”

Very nice post, Dana! One point though: You say “The perception and attitude of the patient must be taken into account, including whether this person even considers themselves to be a patient in the first place” – While some “real” patients (e.g. after stroke) show a lack of insight into their own symptoms (I had some of those while working as a speech pathologist), some “healthy” people who clearly show a very disturbed perception and attitude in real life consider themselves to be completely normal – which is fair enough as long as they don’t harm people around them, and realize the boundaries between their own and other people’s privacies. I have made some really bad experiences with such people. I wouldn’t go as far as calling them patients, but as you say, the spectrum can be VERY broad, i.e. people can lack some serious insight into their behavior that other people would possibly consider as symptomatic.

Really interesting post, and I’m convinced by everything you say here. But I’m keen to broaden out a bit, and ask where the tendency to increasingly pathologize the norm is coming from.

As a lay outsider looking in, a plausible (at least partial) explanation apparently goes like this: there is a major drive to the medicalisation of previously non-medicalised behaviour, because the underlying financial incentives for major pharmaceutical companies to bring this about are enormous. The causal story might run thus: if everything is medicalised, then everything (at least in theory) is open to prescription treatment; the more people who are diagnosed with a condition, the more drugs can be produced to “treat” those conditions; industry insiders pay for/encourage research favourable in this direction, whilst the system is built such that a) “discovering” new “conditions” is professionally advancing, b) “diagnosing” such “conditions” keeps a lot of people in jobs, and therefore finally c) the interplay between researchers, clinicians, pharma-developers moves in the general direction of an increasing medicalised culture, because this benefits everyone involved in the immediate short term (excepting, perhaps, the patients and wider society, who are apparenyl likely to suffer in the longer run).

Obviously that can’t be the whole story – you need more than profit motives to explain the wide-spread cultural shifts towards medicalisation we see in both the US and UK. But do you, as somebody who knows about this “from the inside” (so to speak), think that something like the above story is plausible?

Because if it is, the hopes for reforming attitudes along the lines you suggest look pretty bleak.

Unfortunately, I think you’re exactly right. The commoditization of health is an enormous industry and the consumption of products to make you “better” is a huge moneymaker. In many ways, advertising medical treatments is just like advertising any other product: you create a problem (ADD, restless leg syndrome, dirty floors), you convince people they have this malady and that it is, indeed, a problem that is standing in the way of their ultimate happiness. Then you provide them a product that will get rid of said problem and leave them with a happier, better life.

However, the flip side of this is that these diseases, specifically meaning psychological ones, do exist, and there are numerous people who do suffer and require medical treatment, whether it’s through therapy or pharmaceuticals, and whose lives will improve with this treatment. And for every drug company representative, there is a researcher or a clinician who does genuinely care about the quality of the science and patient care.

I believe the answer to the problem is with the consumer and a higher quality of education, though this too can be a double-edged sword. The internet has provided a powerful resource that can potentially arm people with valuable information and forums for any number of disorders. However, instead of just giving answers and support to those who really are suffering, it can also create an information-induced hysteria and hypochondriasis. This goes way beyond psychological illnesses, and with WebMD and other self-diagnosing websites, a minor rash can turn into skin cancer as fast as you can click your mouse.

There was a fascinating article in the Guardian a couple weeks back about a new “disorder” called morgellons that involves microscopic blue alien fibers found in your skin. There is serious debate about whether this a real disease or not, and with the ability to connect with other sufferers through the internet, this “epidemic” is spreading around the globe. However, this isn’t recognized as a real disorder, there is no diagnosis or treatment or drug for it and no one is making money off of this hysteria.

This is where I think a lot of the over-diagnosing is coming from, but truly it is a multifaceted problem involving all aspects of the medical system. As for the drug companies, ultimately the creation of a drug comes from the demand from suffering patients, although once this need has been established there’s no stopping them from advertising and increasing their prescription numbers.

What you say about “morgellons” is really interesting – a potential wider tendency to hypochondria in society at large, which isn’t coming (at least not simply, directly and in “one-shot” instances) from the activities of big pharma or other corporate actors.

I have a bunch of pet theories for why people go in for this sort of thing, and they’re vaguely clustered around people’s apparent need for fear and suffering. It’s initially counter-intuitive, but one of the striking constants of human history (at least in the west) is that in a big way people go in for collective fear and self-inflicted pain, at least when considered as acting in groups together. Think of witch-crazes, pedophile hysterias, varying degrees of belief in the super-natural; or in more extreme cases the outright murder and persecution of outsider groups;* or on (for example) Nietzsche’s understanding of Christianity, the systematised internalisation of represession and self-harming mechanisms.

Human beings and human societies do very odd things. Seeking out pathologies where they don’t exist, or inventing them where they didn’t before have purchase (even if that means they *really do* start to have purchase further down the line), may be an aspect of human behaviour with a very long history, previously released in other outlets.

Sorry, these are rather late-night and unfocused thoughts. And there’s the risk that it sounds a lot like woo-woo new age pseudo-philosophical horseshit (which perhaps it is), but here’s some of my older thoughts in vaguely this direction:

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* because even if the outsider group gets persecuted and killed, the point is that the insider group builds up a fear *about* the outsiders, and this seems to be a pervasive and recurring characteristic of many (western) societies. We go in for fear in a big way, and that’s very puzzling.

Groupthink and the ingroup-outgroup dynamic is absolutely an innate human tendency. Social psychologists have been researching this for decades and a very large part of these groups that form, whether organically or through directed influence, is playing on the idea of fear. But these groups really do exist on all levels of society, whether just the “us vs them” in sports team alliances or on a larger racial or cultural split.

My philosophy is incredibly rusty (spent more time reading Nature than Nietzsche lately), but I remember Erich Fromm writing about this in Escape from Freedom and the fear of being isolated with autonomy and freedom, and running back to a group to gain a sense of security. Everyone wants to belong, to be part of a community, even if that’s a community of questionable individuals on the internet suffering from delusional parasitosis. You have a name for something, and a group that you can genuinely belong and relate to.

Please all of you, read “Super Brain” written by Dr. Rudy Tanzi and Deepak Chopra!
Their research has put a different light on the functions of BRAIN/MIND.
An excellent read…meant to enhance our well-being